Every finding on record at Lackland Hospice LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) clinical records reviewed revealed that the IDG did not complete an initial comprehensive assessment within 5 days. Record #55089 was reviewed and identified the patient elected the hospice benefit on 12/31/2020. The Medical Social Worker completed an initial assessment on 1/8/2021, 8 days from the date of election of the hospice benefit.. There was no documentation explaining why this assessment was completed late. The Clinical Manager was interviewed on 6/15/2022 and validated that the assessment was late. She had no additional information to provide.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record reviews, observation and interviews. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure the drug profile contains the patient's current prescription, OTC drugs, and supplements. Record #76695 was reviewed and identified that the patient elected the hospice benefit on 9/18/2020. The initial comprehensive assessment by the registered nurse (RN) documented the patient required "O2 @ 10 lpm." The patient's medication profile did not include the oxygen. Record #38165 was reviewed and identified that the patient elected the hospice benefit on 3/5/2021. During the home visit conducted on 6/15/2022, it was identified that the patient was taking "Ibuprofen 800mg po every 8 hours as needed" as of 6/3/2022. The patient's medication profile did not include the medication "Ibuprofen." In addition, the medication profile documented that the patient was prescribed "Omega-3 100mg by mouth every day" and "Gabapentin 100mg by mouth four times a day." During interview the patient's daughter reported the patient is no longer taking these medications. Record #98305 was reviewed and identified that the patient elected the hospice benefit on 9/26/2021. The initial comprehensive assessment completed by the RN documented the patient required "O2 @ 2 lpm." The patient's medication profile did not include the oxygen. The Clinical Manager was interviewed on 6/15/2022 and confirmed that medications were not updated on the medication profile. She had no additional information to provide.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record reviews and interview. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure that the initial comprehensive assessment includes an initial bereavement assessment. Record #65469 was reviewed and identified that the patient elected the hospice benefit on 9/13/2021. There was no evidence that an initial bereavement assessment was completed. Record #78269 was reviewed and identified that the patient elected the hospice benefit on 9/26/2021. There was no evidence that an initial bereavement assessment was completed. The Clinical Manager was interviewed on 6/15/2022 and validated the bereavement assessments were missed on these patients.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes reassessment of the patient’s response to care. This standard was not met as evidenced by clinical record reviews and interview. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure that the update of the comprehensive assessment is completed by the Interdisciplinary group (IDG) members as frequently as the condition of the patient requires, but no less frequently than every 15 days. Record #25598 was reviewed and identified that the patient elected the hospice benefit on 7/7/2021. The IDG notes dated 5/10/2022, 5/24/2022, and 6/7/2022 did not include updates completed by the registered nurse case manager (RNCM). Record #58206 was reviewed and identified that the patient elected the hospice benefit on 9/25/2020. The IDG notes dated 5/10/2022, 5/24/2022, and 6/7/2022 did not include updates completed by the RNCM. Record #40659 was reviewed and identified that the patient elected the hospice benefit on 8/19/2021. The IDG notes dated 5/10/2022, 5/24/2022, and 6/7/2022 did not include updates completed by the RNCM. Record #38165 was reviewed and identified that the patient elected the hospice benefit on 3/5/2021. The IDG notes dated 5/24/2022, and 6/7/2022 did not include updates completed by the RNCM. Record #65469 was reviewed and identified that the patient elected the hospice benefit on 9/13/2021. The IDG note dated 1/19/2022 did not include an update completed by the Chaplain. The IDG notes dated 2/2/2022 and 2/16/2022 did not include updates completed by the RNCM, Medical Social Worker or Chaplain. The Clinical Manager was interviewed on 6/15/2022 and validated that documentation was missing from the IDG notes. She stated a performance improvement plan was created to address this issue. She had no additional information to provide.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record reviews and interview. 1 of 11 (9%) clinical records reviewed revealed that the hospice did not ensure the patient received all services ordered in the plan of care Clinical Record #98305 was reviewed and identified that the patient elected the hospice benefit on 9/26/2021. A physician order dated 9/29/2021 documented, "Physical Therapy to evaluate and treat." The clinical record did not include evidence that a Physical Therapy evaluation was completed. The Clinical Manager was interviewed on 6/15/2022 and confirmed that the physical therapy evaluation was not completed as ordered. She had no additional information to provide.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record reviews and interview. 1 of 11 (9%) clinical records reviewed revealed that the plan of care did not include all required elements. Record #55089 was reviewed and revealed that the patient elected the hospice benefit on 12/31/2020. Oxygen was ordered for the patient at admission. There was no documentation that addressed interventions or goals related to the use of oxygen included in the plan of care. The Clinical Manger was interviewed on 6/15/2022 and validated that the respiratory intervention and goal was missing on the plan of care. She had no additional information to provide.

It is required that plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record reviews and interview. 1 of 11 (9%) records reviewed revealed the hospice did not ensure that all medical supplies were identified in the plan of care. Record #65469 was reviewed and identified the patient elected the hospice benefit on 9/13/2021. The initial registered nurse (RN) assessment identified that the patient was incontinent of bowel and bladder, and required briefs. In addition, the assessment identified that the patient required a hospital bed, side rails, and a wheelchair. The plan of care did not identify the required medical supplies and equipment. The Clinical Manager was interviewed on 6/15/2022 and confirmed that the appropriate information was not present on the plan of care. She had no additional information to provide.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid -certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary, and the patient's clinical record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed of transferred patients revealed the hospice agency did not ensure a discharge summary was forwarded to the receiving Medicare/Medicaid certified facility. Clinical Record #79772 was reviewed and identified the patient elected transfer to another hospice on 11/15/2021. There was no evidence of the transfer paperwork in the patient's medical record. The Clinical Manager was interviewed on 6/15/2022 and confirmed the transfer paperwork was not uploaded to the EMR appropriately. She had no additional information to provide.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record reviews and interview. 2 of 2 (100%) applicable records reviewed of patients who revoked the hospice benefit revealed the hospice did not ensure a copy of the patient's discharge summary was forwarded to the patient's attending physician. Record #65469 was reviewed and identified the patient elected the hospice benefit on 9/13/2021.The patient revoked the hospice benefit on 12/9/2022. The clinical record did not include evidence that the discharge summary was sent to the attending physician. Record #98305 was reviewed and identified that the patient elected the hospice benefit on 9/26/2021. The patient revoked the hospice benefit on 10/17/2021. The clinical record did not include evidence that the discharge summary was sent to the attending physician. The Clinical Manager was interviewed on 6/15/2022 and validated the discharge summaries were not sent to the physician.